Scaphotrapezial Joint Research Articles

Joint capsule innervation does not explain the difference in symptoms between scaphotrapezial and trapeziometacarpal osteoarthritis

ObjectivesPeritrapezial osteoarthritis (OA) includes scaphotrapezial and trapeziometacarpal OA. In clinical practice, scaphotrapezial OA seems better tolerated than trapeziometacarpal OA, with fewer complaints and better tolerance. The difference in pain could be linked to a difference in joint capsule innervation, perhaps with fewer nerve fibers in the scaphotrapezial than the trapeziometacarpal joint. Materials and methodsWe performed a histologic evaluation of these two joints to compare their respective innervation in 17 cadaveric specimens with peritrapezial OA. Radiographic scoring confirmed the presence of peritrapezial OA. Mean Kellgren-Lawrence score was 2.2 ± 1.1 in the trapeziometacarpal joint and 1.5 ± 0.7 in the scaphotrapezial joint (p = 0.08). ResultsThere was no difference between scaphotrapezial and trapeziometacarpal joints in number of neurofilaments: 5.2 ± 3.9 and 4.4 ± 4.5, respectively (p = 0.20). A significant difference was found in S100 staining (myelinated structures), with a higher rate in the scaphotrapezial joint: 11.8 ± 7.5 vs 6.6 ± 5.2 (p = 0.005). ConclusionThe present study suggests that lower tolerance of trapeziometacarpal OA is not due to a difference in joint capsule innervation. On the contrary, we found a higher rate of myelinated tissues in the scaphotrapezial joint. These results suggested other pain pathways to explain clinical observations.

The AIUM Practice Parameter for the Performance of the Musculoskeletal Ultrasound Examination.

The AIUM Practice Parameter for the Performance of the Musculoskeletal Ultrasound Examination.

Surgical management of slightly or non-displaced corporal scaphoid fractures by retrograde percutaneous screw fixation through the anterior trapezium horn: A single-center retrospective French study of 33 patients between January 2015 and January 2019

Percutaneous screw fixation has recently gained popularity as an alternative to conservative treatment to avoid prolonged immobilization. The placement of a screw in the central axis of the scaphoid has been shown to be biomechanically superior to its eccentricity. Still, it poses difficulties in performing percutaneous screw fixation via both palmar and dorsal approaches. We describe a palmar percutaneous screwing of corporal fractures of the scaphoid by a simple palmar transtrapezial approach allowing an optimal centering of the screw. We selected patients operated on by the same surgeon using the palmar transtrapezial approach between January 2015 and January 2019 based on the coding used for these fractures and the operative reports. In addition, pre- and postoperative data were collected from the patient's computer and paper records and by telephone contact with the patients. Thirty-three patients were included. Percutaneous screw fixation of the scaphoid was performed under locoregional anesthesia in the operating room with one arm in the supine position on the arm table. No hyper-extension of the wrist was performed. The Kirchner guidewire passed through the anterior horn of the trapezium and then into the trapezium-scaphoid joint. A screw replaced it after satisfactory centering in the axis of the scaphoid. Management took place on average within 12 days after the trauma. 75.8% were A2 fractures, according to Herbert's classification. The average operating time was 16.63minutes, and in 91% of the cases, the patient was hospitalized for one day. The variation of the scapholunate angle on the preoperative profile radiographs with the angle defined by the axis of the scaphoid screw and the lunate postoperatively was on average 2.94°. One patient presented nonunion, and four showed an undersized screw with a screw overhang requiring revision surgery. The transtrapezial approach to fixation of acute scaphoid fractures facilitates precise percutaneous screw placement in the central axis of the scaphoid. A study of long-term complications, including the degenerative impact on the scaphotrapezial joint, is needed to assess the safety of passage through the anterior horn of the trapezium.

In vivo quantification of the 3D kinematics and coupling of the thumb base joints.

Full thumb mobility is required to execute tasks of daily living and results from the combined motions of the thumb joints. In this study, we focus on the coupling between the proximal joints of the thumb, the radioscaphoid (RS), scaphotrapezial (ST) and trapeziometacarpal (TMC) joints. We quantified the 3D kinematics of these joints during maximal thumb extension and abduction in a group of healthy volunteers using an image-based technique. Semi-dynamic CT scans of the dominant hand of 36 healthy subjects with the thumb in different standardized positions were used. The maximal range of motion of each joint in the different planes was calculated using a markerless bone registration method. Inter-joint coupling was assessed by performing a regression analysis between the range of motion of the joints during both thumb movements. Strong inter-joint coupling was found between the RS and ST joints during thumb extension and abduction, whereas coupling between the other joints was moderate to weak. This study provides valuable information on the in vivo 3D kinematics of the RS, ST and TMC joints during thumb movement. This can be used as input for modeling studies, where the coupling between the joints can decrease the degrees of freedom of the model. Moreover, these baseline data of a healthy cohort can be used for comparison with the kinematics of patients with TMC osteoarthritis or other pathologies and aid our understanding of motion deficits resulting from these joint disorders.

The Effect of Malunited Scaphoid Fractures on Joint Congruency

Although the consequences of scaphoid nonunion have been well-established, the implications of malunions are not well-known. To date, malunions have mainly been studied with 2-dimensional imaging. The objective of this study was to employ 3-dimensional computed tomography (CT) imaging and inter-bone distance mapping to determine the implications of a scaphoid malunion on 3-dimensional joint surface area (JSA) (a measure of joint contact area) at an average of 7 ± 2 years (range, 4-12 years) after fracture. In 14 subjects with previous unilateral, malunited scaphoid fractures, we measured the 3-dimensional JSA using reconstructed CT bone models of the carpus. The JSA was compared within each individual, comparing images of the wrist collected at the time of fracture (baseline) and 7 years later (follow-up CT scans). There was a significant increase in the measured JSA (reduced joint space) at the scaphotrapezial (23% increase) and scaphocapitate (13% increase) joints when the baseline and follow-up scans of the wrist were compared. An increased JSA indicates that the 2 opposing surfaces are closer in contact and have a reduced joint spacing reflective of degenerative changes. However, participants in this study showed no radiographic signs of degenerative changes in the wrists at midterm follow-up. An increase in JSA was found in patients with a malunited scaphoid in the scaphotrapezial and scaphocapitate joints of the wrist an average of 7 years after injury, but these joint changes were not evident in measured radiographic signs of arthritis. As early as 4 years after injury, the 3-dimensional JSA is significantly increased at the scaphocapitate and scaphotrapezial joints. Future work is needed to determine the implication of this increased in 3-dimensional JSA on the underlying subchondral bone, and to observe these patients for longer to determine whether degenerative changes develop.

In vivo kinematics of the thumb during flexion and adduction motion: Evidence for a screw-home mechanism.

The thumb plays a crucial role in basic hand function. However, the kinematics of its entire articular chain have not yet been quantified. Such investigation is essential to improve our understanding of thumb function and to develop better strategies to treat thumb joint pathologies. The primary objective of this study is to quantify the in vivo kinematics of the trapeziometacarpal (TMC) and scaphotrapezial (ST) joints during flexion and adduction of the thumb. In addition, we want to evaluate the potential coupling between the TMC and ST joints during these tasks. The hand of 16 asymptomatic women without signs of thumb osteoarthritis were CT scanned in positions of maximal thumb extension, flexion, abduction, and adduction. The CT images were segmented and three-dimensional surface models of the radius, scaphoid, trapezium, and the first metacarpal were created for each thumb motion. The corresponding rotations angles, translations, and helical axes were calculated for each sequence. The analysis shows that flexion and adduction of the thumb result in a three-dimensional rotation and translation of the entire articular chain, including the trapezium and scaphoid. A wider range of motion is observed for the first metacarpal, which displays a clear axial rotation. The coupling of axial rotation of the first metacarpal with flexion and abduction during thumb flexion supports the existence of a screw-home mechanism in the TMC joint. In addition, our results point to a potential motion coupling between the TMC and ST joints and underline the complexity of thumb kinematics. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1556-1564, 2017.

Percutaneous Scaphoid Screw Fixation

Hypothesis: Application of a screw to the fractured scaphoid as perpendicular to the plane of the fracture as possible is a key to proper healing. Using the previously proposed radiographic predictor of healing that uses the sum of smaller angles (SSA) of intersection between the proposed screw position and the plane of the fracture in 3 radiographs (posterior anterior [PA] in ulnar deviation, 45 pronation, and supination oblique), we suggested classifying fractures of the scaphoid into volarly accessible “V type” and dorsally accessible “D type” according to the SSA >160° and <160°, respectively. The proximal pole of the scaphoid at the dorsal apex is considered V type and proximal to it is considered D type. Methodology: Prospectively, we fixed the 176 scaphoid fractures percutaneously between 2005 and 2013. The proposed screw passage through the retrograde route was drawn on the 3 mentioned radiographs and the SSA was calculated. We classified 133 fractures (75.6%) as V type (113 waist and 20 proximal pole) and 43 fractures (24.4%) as D type (27 waist and 16 proximal pole). The V type fractures were fixed through retrograde route by cannulated Herbert screw and the D types through antegrade route using mini-incision to protect the extensors and avoid capsular teathering exposing the screw entry. No immobilization was used for both methods and we allowed early range of motion (ROM) exercises a early return to office work. Patients with gross comminution or associated fracture or ligament injury were excluded from this study. Results: In the V type, union occurred in all but one patient (99.2%) at a mean 7.6 weeks (6-12) with no need to supplementary antiglide wire. Two patients with screw prominence in the scaphotrapezial joint needed screw removal after bone union. Five of 85 patients had radiographic scapho-trapezium-trapezoid arthrosis after 5 years, but asymptomatic. In the D type, union occurred in all patients (100%) at a mean 8.1 weeks (6-12). Two patients with screw prominence in the radioscaphoid joint had screw remotion after union; three patients had a painful scar and one had extensor pollicis longus (EPL) adhesions. Both groups had comparable demographics, union rate and time, complication rate, and need for second surgery. Conclusion: Classifying scaphoid into V and D types help the choice of proper fixation route for predictable outcome.

A new surgical technique for the treatment of scaphotrapezial arthritis associated with trapeziometacarpal arthritis: the narrow pseudoarthrosis.

We describe a technique for treating Eaton stage IV osteoarthritis of the first ray, which is a development of our previously published technique for treating trapeziometacarpal arthritis. This simple technique is based on a limited resection arthroplasty of the first trapeziometacarpal and the scaphotrapezial joints, with the aim of inducing the formation of a narrow pseudoarthrosis at both sites. A total of 26 consecutive patients were treated for Eaton stage IV arthritis at a mean follow-up of 4.7 years (range 3.2-6.6). There were statistically significant improvements in all clinical parameters: mean appositional and oppositional pinch strength, mean DASH score (65 points pre-operatively to 8.7 points at final follow-up), and in mean visual analogue scale score (8.6 to 0.2 points). Although a larger cohort and a longer follow-up will be necessary to evaluate this new technique fully, these results encourage us to believe that the limited excision arthroplasty of the trapeziometacarpal and scaphotrapezial joints is a viable alternative to the existing surgical treatments for stage IV thumb arthritis. 4.

No correlation between severity of preoperative degenerative changes in the trapeziometacarpal joint and short-term clinical outcome after total joint arthroplasty

In this study, we wanted to investigate whether the severity of preoperative degenerative changes in the trapeziometacarpal (TM) joint seen on CT scans would influence the clinical outcomes after total TM joint arthroplasty, and particularly whether discrete degenerative changes in the scaphotrapezial (ST) joint would negatively affect the clinical outcome. Patients classified as Eaton–Glickel stage 2 or 3, as well as patients with Eaton–Glickel stage 4 disease who had discrete degenerative changes in the ST joint (i.e., narrowing and sclerotic changes but no osteophytes) were included in the study; patients with more severe degenerative changes of the ST joint were excluded. Follow-up was done using the Disability of Arm, Shoulder and Hand (DASH) score at 3, 6 and 12 months after surgery together with grip strength and pain using a 100-mm visual analog scale. In all, 59 patients with 69 total joint arthroplasties were included in the study; there were 47 females and 12 males with a mean age of 59 years (range 41–77). We found no significant difference between the three patient groups in their improvement in grip strength from preoperative to 12 months. Also we found no statistically significant differences in the DASH score or pain level at rest or during activity between the preoperative and all the postoperative time points. Total TM joint arthroplasty can produce excellent short-term clinical results with a good restoration of grip strength and function. Discrete degenerative changes in the ST joint appear not to be a contraindication for treating TM joint osteoarthritis with total joint arthroplasty.

Median nerve neuropathy in the forearm due to recurrence of anterior wrist ganglion that originates from the scaphotrapezial joint: Case Report

BackgroundMedian nerve neuropathy caused by compression from a tumor in the forearm is rare. Cases with anterior wrist ganglion have high recurrence rates despite surgical treatment. Here, we report the recurrence of an anterior wrist ganglion that originated from the Scaphotrapezial joint due to incomplete resection and that caused median nerve neuropathy in the distal forearm.Case presentationA 47-year-old right-handed housewife noted the appearance of soft swelling on the volar aspect of her left distal forearm, and local resection surgery was performed twice at another hospital. One year after the last surgery, the swelling reappeared and was associated with numbness and pain in the radial volar aspect of the hand. Magnetic resonance imaging revealed that the multicystic lesion originated from the Scaphotrapezial joint and had expanded beyond the wrist. Exploration of the left median nerve showed that it was compressed by a large ovoid cystic lesion at the distal forearm near the proximal end of the carpal tunnel. We resected the cystic lesion to the Scaphotrapezial joint. Her symptoms disappeared 1 week after surgery, and complications or recurrent symptoms were absent 13 months after surgery.ConclusionsA typical median nerve compression was caused by incomplete resection of an anterior wrist ganglion, which may have induced widening of the cyst. Cases with anterior wrist ganglion have high recurrence rates and require extra attention in their treatment.

Volar Percutaneous Screw Fixation of the Scaphoid: A Cadaveric Study

To test the efficacy of a previously described technique of angiocatheter-assisted instrument positioning in achieving a central screw position in a cadaveric model for volar percutaneous screw fixation (PSF) of the scaphoid and to quantify the damage to surrounding soft tissue and articular cartilage associated with the procedure. We performed fluoroscopically guided volar PSF of the scaphoid on 10 fresh cadaveric wrists. We then dissected the specimens, analyzed screw position in cross sections of the scaphoid, and described injury to nearby soft tissue structures as well as articular cartilage of the scaphotrapezial joint. All 10 screws were positioned within the central third of the scaphoid on at least 2 of 3 cross sections, and 8 of 10 screws were positioned within the central third of the proximal pole. Two wrists required a transtrapezial trajectory for satisfactory screw positioning. None of the specimens sustained visible neurovascular damage, and 2 wrists revealed minor tendon damage. Trajectories involving the scaphotrapezial joint violated, on average, 7% of the scaphoid articular cartilage. With a transtrapezial trajectory, 11% of the trapezial cartilage was violated Central positioning of the screw is biomechanically superior, and screw position within the central one third of the proximal pole has been associated with faster time to union. Volar PSF achieved satisfactory screw position in the scaphoid. The majority of wrists were amenable to PSF via the scaphotrapezial joint, though a transtrapezial approach was a viable alternative for wrists with restrictive anatomy. Both approaches minimally disrupted the scaphotrapezial joint and surrounding soft tissues. Therapeutic IV.

Guest Editorial

Guest Editorial

Percutaneous fixation of acute scaphoid fractures

BackgroundFractures of the scaphoid are common in young men. Cast immobilization usually means a long period away from work and athletic activities. Early rigid fixation has been shown to promote a rapid functional recovery, but open reduction and internal fixation is technically demanding with the risk of damage to the radiocarpal ligaments, the scaphotrapezial joint, and the blood supply of the scaphoid.PurposeThe aim of this prospective case series study was to evaluate percutaneous scaphoid fixation for minimally displaced or undisplaced B1 or B2 fractures with respect to time to radiographic union and return to work.Patients and methodsWe report our technique and the results of a prospective study in 12 patients with acute scaphoid fractures. Patients were assessed functionally using the Mayo wrist score and by radiography. The patients were followed up until evidence of radiologic union (35-70 days), with an average of 55 days.ResultsTen patients had excellent score and two patients had good score according to the Mayo wrist score. According to patients' occupations, return to work ranged from 14 to 40 days. With respect to radiologic union, fractures were united at a mean of 55 days (35-70 days).ConclusionPercutaneous fixation for acute scaphoid fractures using Herbert screws is a satisfactory method and gives rapid functional recovery.

Use of the transverse carpal ligament for soft tissue reconstruction of a Mannerfelt lesion

In 1969, Mannerfelt described the “critical corner” where the flexor pollicis longus (FPL) tendon tends to rupture from abrasion against osteophytes from the scaphotrapezial joint in patients with rheumatoid arthritis [2]. He further suggested that removal “of the spur and covering of the floor…may have saved these tendons from later attritional rupture.” Since then, it has been recognized that debridement of osteophytes and soft tissue reconstruction, to separate the arthritic wrist joint from the carpal canal, are important to avoid recurrent rupture following tendon reconstruction. The currently accepted method of soft tissue reconstruction uses the adjacent capsulo-ligamentous transposition flap to cover the exposed bone (Fig. 1) [1]. Although the transposition flap appears simple in illustration, we have found this approach to be difficult. The flap is limited in size and does not transpose easily, the donor site is difficult to close, and the soft tissue tends to be of poor quality. In the case of a large defect, a local transposition flap is inadequate to reline the carpal canal. Fig. 1 The recommended reconstruction for Mannerfelt lesions from Green's Operative Hand Surgery (reproduced with permission from Wolfe SW, Hotchkiss RN, Pederson WC, et al., editors, Green's Operative Hand Surgery, 6th edition We have utilized an alternative to the traditional approach of a local transposition flap. A large, radially based flap of the transverse carpal ligament can be used to resurface and reconstruct the volar soft tissues of the wrist along the carpal canal. Given the technical ease of this alternative approach, we report a case and revisit the management of the Mannerfelt lesion.

Optimal Fixation of Oblique Scaphoid Fractures: A Cadaver Model

Acute scaphoid fractures are commonly fixed with headless cannulated screws positioned in the center of the proximal fragment. Central placement of the screw may be difficult and may violate the scaphotrapezial joint. We hypothesize that placement of the screw through the scaphoid tuberosity will achieve perpendicular fixation of an oblique waist fracture and result in more stable fixation than a screw in the center of the proximal fragment. We designed oblique osteotomies for 8 matched pairs of cadaver scaphoids and fixed each specimen with a headless cannulated screw. In 1 specimen, we positioned the screw at the center of the proximal fragment; we placed its matched pair perpendicular to the fracture. The perpendicular screw was directed through the scaphoid tuberosity. We placed the specimen under the increasing load of a pneumatically driven plunger. We compared stiffness, load, distance at failure, and mechanism of failure between the central and perpendicular screw groups. We found no difference between groups. Stiffness was identical in both groups (131 N/mm) and load to failure was similar (central screw, 137 N vs perpendicular screw, 148 N). In this biomechanical model of an unstable scaphoid fracture, we found that similar stability of fixation had been achieved with a screw perpendicular to the fracture plane with entry through the tuberosity, compared with a screw in a central position in the proximal fragment. This study suggests that placing the screw through the tuberosity, perpendicular to a short oblique fracture, will not impair fixation stability. Percutaneous fixation of scaphoid fractures has become popular although it is technically challenging. An easier distal approach through the tuberosity, without violating the scaphotrapezial joint, may not impair the fixation stability of an oblique fracture.

The Scaphotrapezial Joint After Partial Trapeziectomy for Trapeziometacarpal Joint Arthritis: Long-term Follow-up

Partial trapeziectomy addresses trapeziometacarpal (TM) joint arthritis without the risk of destabilizing the scaphotrapezial (ST) joint. However, partial trapeziectomy has been criticized because of concern that ST joint arthritis will develop, requiring additional surgery. We hypothesized that partial trapeziectomy is a durable treatment for TM joint arthritis, even in patients with radiographically abnormal but asymptomatic ST joints. We evaluated 13 patients (16 thumbs) who underwent a partial trapeziectomy between 1995 and 2005. Assessment included grip strength, pinch strength, ST joint direct palpation, and ST joint stress testing. We classified standardized radiographs of the ST joint using a simple scoring system. Subjective data included the Disabilities of the Arm, Shoulder, and Hand questionnaire, a pain scale, and a satisfaction survey. The length of follow-up averaged 9 years (range, 5-13 y). No patient had pain at the ST joint with direct palpation or stress testing. Radiographs demonstrated a mean ST joint arthritis score of 1, indicating mild arthritic changes. Mean grip strength was 28 kg on the operated hand and 28 kg on the nonoperated hand. Mean pinch strength was 5 kg on the operated hand and 5 kg on the nonoperated hand. Scores on the pain scale averaged 6 (range, 0-100; 100 = worst). Average Disabilities of the Arm, Shoulder, and Hand score was 11 (range, 0-100; 100 = worst). Of 13 patients, 12 were very satisfied or extremely satisfied, and 1 was not satisfied. Partial trapeziectomy for TM joint arthritis provides long-lasting relief of symptoms in patients with radiographically abnormal but clinically insignificant ST joint degeneration. Satisfaction is equivalent to other published series. The radiographic appearance of the ST joint did not correlate with symptoms at this joint. Unless the patient has symptomatic ST joint arthritis, the ST joint may be retained. Therapeutic IV.

SYNOVIAL FRINGE (PLICA) OF SCAPHO-TRAPEZIAL JOINT FOLLOWING TRAUMA

We herein present a case of radial wrist pain following trauma. Magnetic resonance imaging showed a large area of abnormal soft tissue in the scapho-trapezial joint. The patient was treated successfully by complete resection of the soft tissue. The soft tissue was diagnosed to be synovial fringe based on a histological study. Synovial fringe is frequently reported as a cause of knee and elbow pain, however, it is a rare cause of wrist pain at the scapho-trapezial joint.

Incidence of Scaphotrapezial Arthritis Following Volar Percutaneous Fixation of Nondisplaced Scaphoid Waist Fractures Using a Transtrapezial Approach

To investigate whether volar percutaneous screw fixation of scaphoid waist fractures via a transtrapezial approach causes degenerative changes at the scaphotrapezial (ST) joint at short- to medium-term follow-up. A total of 34 patients were available for follow-up at a mean of 6.1 years (minimum follow-up, 3.7 y) after volar percutaneous fixation of acute scaphoid waist fractures via a transtrapezial approach. The clinical follow-up examination included assessment of pain using a visual analog scale, range of motion, grip strength, and key pinch strength. We obtained radiographs of both hands in 3 views. We staged degenerative changes at the ST joint according to the modified Eaton and Glickel classification. The modified Mayo wrist score showed excellent clinical results using the described technique. One patient showed asymptomatic unilateral stage 2 osteoarthritic changes at the ST joint. We noted 6 screw protrusions, which required screw removal in 2 patients, in the early stages of use of the transtrapezial technique. One patient was treated surgically for a bone cyst. Volar percutaneous screw fixation of nondisplaced scaphoid waist fractures using a transtrapezial approach does not lead to symptomatic scaphotrapezial osteoarthritis at short- to medium-term follow-up. Therapeutic IV.

Nondisplaced scaphoid fractures

Evidence from seven randomized (or quasi-randomized) controlled trials suggests that patients receiving internal screw fixation may heal more quickly and return to work sooner than patients receiving cast immobilization for treating nondisplaced scaphoid fractures. Similar rates of union in both operative and nonoperative groups were seen, and grip strength and range of motion outcomes were not significantly different between the two groups in studies reporting follow-up of 1 year or longer. Long-term studies showed a slight reduction in range of motion for operatively treated patients, but statistical significance was not uniformly reported. Two of three long-term studies reported a significant increase in incidence of osteoarthritis in the scaphotrapezial joint among operatively treated individuals. It appears that some benefits of operative management may occur within short time frames, including faster healing and quicker return to work and normal activities, however functional outcomes were similar, particularly at longer follow-up.

Percutaneous Transtrapezial Fixation of Acute Scaphoid Fractures

Percutaneous screw fixation of undisplaced fractures of the scaphoid waist has gained popularity but remains technically demanding. This study describes a transtrapezial modification of the volar percutaneous technique and reports the results in 41 patients. The patients were evaluated at a mean of 36 months (range 14-68 months) after surgery. All fractures healed within 10 weeks (mean 6.4 weeks). Functional ranges of wrist motion and grip strength were achieved in all patients. Radiographs showed accurate central placement of the screw in all patients and no degenerative changes were seen at the scaphotrapezial joint. In three patients, the screw was removed because it was prominent at the scaphotrapezial joint.